Graft selection in reconstruction of the anterior cruciate ligament.

Only 20 years ago reconstruction of the anterior cruciate ligament (ACL) involved an open intra-articular operation in which the graft was placed in a position where it was not anatomical and which involved opening both the medial and lateral capsules. There was a long scar and considerable analgesia was required after the operation. The patient remained in hospital for ten days and in a cast for six weeks. Now, a less invasive procedure allows positioning of the graft to give a full range of movement without impingement and with restoration of stability. Which type of graft is now used? A poll of members of the Australian Knee Society in 2000 revealed that all used autograft only, with 58% employing both patellar tendon and hamstring grafts in certain circumstances; the remainder were evenly divided in their preference for ‘only’ patellar tendon or ‘only’ hamstring. Members of the ACL Study Group showed a different perspective, with 73% choosing the patellar tendon, 23% the hamstrings and 4% ‘others’, such as allografts. This had not changed from a previous survey two years earlier. Another survey of orthopaedic surgeons caring for American football teams in the major leagues showed that all but one chose autologous patellar tendon grafts. This article evaluates the available choices of graft and examines their advantages and disadvantages, the clinical outcomes, morbidity at the donor site, biomechanical characteristics and healing. We consider whether certain grafts are more suitable in particular cases and speculate as to the future directions of surgery of the ACL considering tissue engineering, growth factors and gene therapy. Choices of graft